Error Prevention Process Overview

57 Pages·2011·5.9 MB·English

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J.Allison Copyright ©2010 United Launch Alliance, LLC. All Rights Reserved.
Error Prevention Process
Objective
(cid:137)
–Share ULA’s Error Prevention Process & Experience
• ULA & Error Prevention Background/History
• Error Prevention Specific Definitions
• ULA Error Prevention Process Overview
• ULA Error Prevention Publications
• More Lessons Learned
–Questions are Always Welcome
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Background: Who/What is ULA?
ULA Launch Vehicles
United Launch Alliance
•Formed in 2006 as a 50-50 Joint Venture Between Atlas Delta
Lockheed Martin & Boeing
•Provides Two World Class Launch Systems Operating
as a Single Provider to the U.S. Government
– Atlas V Product Line
– Delta IV Product Line
– Delta II Product Line
•Employs More Than 3500 Employees
•More Than a Century of Combined Experience in
Expendable Launch System Production & Operation
Providing Assured Access to Space
•Pooled Experience of Nearly 1300 Launches 440011 443311 555511 HHLLVV DDeellttaa 22 MMeeddiiuumm 44 MMeeddiiuumm 55,,44 HHeeaavvyy
•Legacy Reaching Back to 1950s
Vandenberg Air
Force Base
Denver, CO
(VAFB), CA
Decatur, AL
Pueblo, CO
San Diego, CA
Harlingen, TX
Cape Canaveral
Air Force Station
(CCAFS), FL
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Great News!
ERRORS
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Identify the Hazards
Recognizing When
Others are Taking a
Risk is Easy
Recognizing When You
are About to Take a
Risk Requires Both
Effort & Practice
STOP & THINK Before
You Act
STOP When Risks/
Hazards Exist
Picture used with permission from thereifixedit.com;
There, I Fixed It™ is a trademark of Pet Holdings, Inc. © 2007-2010 Pet Holdings, Inc.
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ULA Error Prevention History
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TIROS Satellite # #
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Incident
LMC Atlas/Boeing Delta ULA
2003 2004 2005 2006 2007 2008
LMC SSC EPC ULA EPC
Atlas Operational Fishbones ULA
Mandatory Error Prevention Training for ALL Employees ULA
Delta Reporting
ULA SS Command Media
• Active Atlas Reporting Since 2004
Err Prev Publications
• Full Implementation of Delta Reporting Began in 2008
On-site Error Prevention
Support Organization Reporting
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Definitions
Event: An incident that has a negative impact on
production or launch operations. An EVENT is
considered a potential MISHAP warning.
Mishap: An EVENT resulting in incurred costs over
$20K or consequences with high or significant impact.
Critical Mishap: A Mishap resulting in incurred costs
over $100K.
Support Organization Event: An EVENT that occurs
as a result of a Support Organization’s action.
EVENT MISHAP
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Definitions
AESOP™ Huddle: An Error Prevention
technique used to ensure that all personnel
associated with an operation are familiar
with & understand their roles &
responsibilities in the operation & that
risks of failure are identified & mitigated.
Flash Notice: A preliminary notice to
Executive Management & other personnel
that a Mishap or Event has occurred.
Corrective Action Board (CAB): A board
to ensure effective corrective action
processes are implemented & closed.
CAB evaluates issues/problems/products/
processes & approves or directs corrective
actions as necessary to remedy critical
problems in a timely manner.
AESOP™is a federally protected trademark of the Error Prevention Institute, Inc.
©2000 Error Prevention Institute, Inc., 888-0599-8715, all rights reserved.
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Definitions
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in everything
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we do
Perfect Product Delivery Ethic:
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• Continuously
• Relentless pursuit of perfection to achieve excellence in imeeevvvpeeerrrryyyo pppvrrreooo ccceeeesssvssse aaarnnnyddd
everything we do; process & product
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• Applies our passion for Mission Success to continuously
improve every process and product, to completely meet ••••DDDDeeeevvvveeeelllooolpppo paaa wwwaooo rrrlllddd---ccclllaaassssss
world-class
the needs of every customer; and wwwooorrrkkk eeennnvvviiirrrooonnnmmmeeennnttt
work environment
• Inspires and empowers all employees to dedicate our
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innovative talents to deliver program success and develop • Deliver program
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a world-class work environment.
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ULA Error Prevention Process Technical Paper Available:
Learning from Mistakes: ULA’s Error Prevention Program
by James E. Allison
Presented at the International System Safety Conference 2009
“The successful man will profit The ULA Error Prevention Process Flow is
from his mistakes and try again in Fed by Ongoing Voluntary Event Disclosure
a different way. ” –Dale Carnegie
Error Prevention
Process Flow
This Paper Describes How United Launch
Alliance’s (ULAs) Error Prevention Program
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Applies This Concept to Rocket Production,
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ULAs Error Prevention Program
Event Disclosures
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• Recognizes Errors as Learning
Via Workforce
Opportunities ••CCoonnttiinnuuoouussllyy iimmpprroovvee Cause Analysis
Cause Analysis
• Encourages Error Reporting Instead eevveerryy pprroocceessss aanndd && C Coorrrerecctitvivee A Acctitoionn
Process
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• Extracts & Shares Lessons Learned wwoorrkk eennvviirroonnmmeenntt Corrective Action
Corrective Action
Company Wide BBooaardrd
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• Issues Action Items to Reduce Error
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Occurrence Company Wide
Error Prevention
Error Prevention
Council
Continuous Feedback Council
Each Reported Error is Tracked Through Review Process
Review Process
Encourages Ongoing Disclosure:
Resolution as Follows
•Company Wide Event Reporting
• Root Cause Analysis
•Weekly Attention To Detail Emails Share Lessons
• Corrective Action Review Boards (CABs) Share Lessons
•Periodic Safety Bulletin Releases Learned Process
Learned Process
• Executive Management Review (Called •Error Prevention Web Site Access
an Error Prevention Council or EPC)
Published Copy Available
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